Current State of Empyema Management

Abstract

Background: Empyema affects up to 65,000 patients annually in the United States. Recent consensus guidelines demonstrate ambiguity about optimal treatment. We examined current treatment practices and outcomes for inpatient treatment of empyema using a comprehensive, longitudinal data set that encompasses an entire state cohort of hospitalized patients.

Methods: We queried the Healthcare Cost and Utilization Project New York State Inpatient Database (2009 to 2014) for patients with primary empyema and subsequent readmissions. Patients were categorized into three groups by definitive treatment during their initial hospitalization: chest tube drainage, video-assisted thoracoscopic surgery (VATS) decortication and drainage, or open decortication and drainage. Treatment outcomes, including success rates, readmission, reintervention, and mortality, were compared between groups.

Results: The cohort included 4,095 patients undergoing intervention for primary empyema discharged during this period with chest tube, VATS, or open drainage and decortication. Most patients received definitive operative management (chest tube: 38.2%, VATS: 32.1%, open: 29.8%; p < 0.001). Patients had a high mortality rate during their initial hospitalization (chest tube: 15.4%, VATS: 4.7%, open: 6.0%; p < 0.001) and a substantial 30-day readmission rate for empyema (chest tube: 7.3%, VATS: 3.8%, open: 4.1%; p < 0.001), with reintervention at readmission significantly higher for chest tube (6.1%) vs surgical patients (VATS: 1.9%, open 2.1%; p < 0.001).

Conclusions: This study characterizes recent treatment practices of patients with empyema. Higher readmission and reintervention rates were observed in patients managed with chest tubes, suggesting some of these patients may benefit from earlier definitive surgical intervention.

Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1

Patient Flow Diagram. This shows the application of inclusion and exclusion criteria, and the resulting patient records used for analysis. Code and treatment frequencies shown here correspond to the percentage of patient records that carried these diagnoses or procedures in any of their codes; many patients had more than one relevant diagnosis or procedure.

Figure 2

Initial Management Breakdown and Success of Chest Tube Drainage during the Index Hospitalization.

Figure 3

Success Rates with a Single Procedure by Initial Intervention. (NR*=not reported. HCUP prohibits reporting numbers of records

Figure 4

Definitive treatment options have remained stable over time.